Prediction of individual dosage of nortriptyline in depressed elderly outpatients.

Individual daily dosages of nortriptyline (NT) can be predicted from administration of a 50-mg or 100-mg single test dose, with a determination of the plasma level 24 hours later. Because the 50-mg or 100-mg test dose used in previous studies may cause unmanageable acute side effects in elderly patients, a 25-mg NT test dose was used to establish a 24-hour plasma level in 18 physically healthy, moderately depressed, geriatric outpatients. Correlations between the 24-hour test dose plasma level and steady state levels were done for maintenance dosages of 50, 75, and 100 mg/day. A nomogram was made from the regression equations to predict the dosage required to achieve a steady state concentration within a 50 to 150 ng/ml range. The importance of the ability to predict NT dosage requirements in geriatric patients is indicated by findings that at daily NT doses of 50 and 100 mg, nearly one-half of subjects had steady state levels below or above 50 or 150 ng/ml, respectively.

Pretreatment orthostatic hypotension as a predictor of response to nortriptyline in geriatric depression.

The consequences of orthostatic hypotension, a serious and common problem among the elderly, are falls, transient ischemic attacks, strokes, and myocardial infarctions. Depressed elderly taking tricyclic antidepressants (TCAs) are at increased risk, and the pretreatment presence of orthostatic hypotension is considered a relative contraindication to TCA treatment. Recently, it was reported that the presence of pretreatment orthostatic hypotension in geriatric outpatients with unipolar depression predicted good clinical response to imipramine or doxepin. We investigated the predictive value of pretreatment systolic orthostatic pressure changes (PSOP) in unipolar depressed elderly outpatients (mean age, 64) who were to receive a 16-week course of nortriptyline or interpersonal psychotherapy. Overall, PSOP was significantly correlated with improvement on both the Beck Depression Inventory and the Hamilton Depression Rating Scale. Although both groups responded equally to treatment, PSOP was more strongly correlated with improvement on the Beck Depression Inventory (r = 0.74, p less than 0.01) in the nortriptyline-treated group than in the group treated with interpersonal therapy (r = 0.31, not significant). The nortriptyline-treated subjects with a PSOP of greater than or equal to 10 mm Hg had a greater improvement than those with a PSOP of less than 10 mm HG (t = -2.36, p less than 0.05). No episodes of symptomatic orthostatic hypotension occurred in the nortriptyline-treated subjects. The results suggest that orthostatic hypotension, a relative contraindication to TCA use, may potentially identify patients more likely to respond to TCAs.

Decreasing the burden in families caring for a relative with a dementing illness. A controlled study.

The purpose of this study was to investigate the efficacy of a specifically designed group support program for relatives of patients with Alzheimer's disease and related disorders. The group program included educational/supportive activities and used basic principles of the cognitive-behavioral approach. Twenty-two subjects participated in an eight-session program. Eighteen control subjects received no treatment. Measures of family burden, levels of depression, and knowledge of dementia were obtained. Experimental subjects showed a significant decrease in total family burden, whereas control subjects actually showed a significant increase, experimental subjects also showed reduction in their levels of depression. Experimental subjects showed a significantly greater improvement than did control subjects on knowledge of dementia. The acquisition of new knowledge was an important ingredient in reducing perception of burden and levels of depression, but other facets of the intervention also accounted for the improvement. Results indicated that a relatively short but intensive support experience can have a positive effect in reducing some of the burden and depression associated with the care of a demented relative.

Health needs of the Hispanic elderly.

This paper presents results of a study concerning the health care needs of the Hispanic elderly population of Los Angeles County. By use of the Comprehensive Assessment and Referral Evaluation (CARE) instrument, data on a sample of 704 subjects were employed to compute the scores for 22 Likert-type scales measuring the prevalence of numerous psychiatric, medical, and social problems. The data indicate that older Hispanics were affected by cognitive impairment (13.8 per cent), depression/demoralization (30.8 per cent), heart disorders (12.8 per cent), stroke effects (11.5 per cent), arthritis (28.3 per cent), hypertension (23.7 per cent), financial hardship (28.0 per cent), fear of crime (38.4 per cent), ambulation problems (17.2 per cent), or activity limitation (24.7 per cent); they also needed assistance (19.3 per cent) or used social services (22.0 per cent). Further analysis revealed that the prevalence of many of these problems varies significantly according to the age, sex, language, and income of respondents. The indicators of health care needs used in the study differed substantially from the more traditional measures based on the person's own perception of his or her health.

Urinary phencyclidine excretion in chronic abusers.

Data on usage patterns of 100 hospitalized chronic phencyclidine abusers was collected. Weekly urine samples were monitored using a new gas chromatographic nitrogen detector analysis for PCP. Abusers were found to be, on the average, young males who had used PCP for approximately 40 months (range 12 to 96 months) and approximately 3 to 4 d/week. Except for one subject, urines became negative for PCP within 30 d after last use with a mean of 14 d. There was rapid excretion during the first 9 d followed by a more gradual reduction in urine PCP levels.

A prospective psychological study of 50 female face-lift patients.

Fifty female face-lift patients were evaluated preoperatively with psychological tests and psychiatric interviews. Their postoperative psychological courses were studied for up to 6 months. Approximately 30% had postoperative depressive reactions. These reactions were primarily correlated with a preexisting, clinically detectable depression, high depressive Beck scores, or a depression-prone personality pattern. There was no statistical correlation between postoperative depressive reactions and magical expectations, post-operative complications, marital status, recent bereavement, relationships with spouse and family, or concerns about death. Preoperative depression scores were often transiently intensified postoperatively, but usually eventually stabilized at a level lower than the preoperative scores. Many women showed postoperative psychological improvement. Twenty-eight percent had an increase in self-esteem, 8% felt better able to cope with life, and 8% were more assertive and confident in their work. The desire to improve self-image and to advance in a career were reasonably reliable predictors of psychological improvement.

Patients' requests of an outpatient clinic.

Three-hundred-twenty-five consecutive predominantly lower-class new patients at a psychiatric outpatient clinic rated the importance they attached to each of 14 categories of treatment needs or requests. Psychiatric residents subsequently rated the importance of each request for each patient at the conclusion of their initial assessment interview. Requests reflecting needs for intrapsychic therapy, clarification, and control of feelings were considered very important by approximately two thirds of the patients; needs for institutionalized contact, advice, and community triage by one half; and other requests for medication, reality contact, succorance, ventilation, confession, social intervention, administrative requests by a minority (one fourth to one third). Residents significantly underestimated the importance their patients attached to 10 of 14 requests. Factor analyses confirmed several systematic sources of disparity between patient and therapist perception of lower-class patient needs.

Personality changes and compatibility in the psychiatric resident--supervisor relationship.

Seventy-one psychiatric resident-supervisor dyads were studied in terms of Schutz's interpersonal theory of compatibility. Personality changes during the second year of psychiatric residency were also measured by means of Schutz's Fundamental Interpersonal Relations Orientation Scale. Predictions relating compatibility to satisfaction with the dyad and to ratings of competence were not confirmed. Personality changes were found, with residents showing a significant decrease in needs for wanting to be included and for expressing affection. Situational factors are proposed for the personality changes, and personality factors are suggested as influencing the selection of psychiatry as a medical specialization.

Patients' attitudes toward behavior therapy and psychotherapy.

A questionnaire survey of 50 patients treated by behavior therapy or short-term, analytically oriented psychotherapy revealed that both groups, as well as those patients who improved the most, placed a high value on insight, the patient-therapist relationship, catharsis, and trust. The findings suggest that behavior therapy patients tend to place more emphasis than do their therapists on factors that have traditionally been thought important in analytic psychotherapy.

Who gets supervised? An extension of patient selection inequity.

A study of 89 individual psychotherapy patients followed by 17 residents in a teaching clinic demonstrated that those presented for supervision significantly differed from the others in being younger, better educated, and better liked by residents and in having higher incomes and longer term treatment. The authors discuss the implications of these findings in relation to the inequity in service time and teaching emphasis that this selection allows.

Psychological characteristics of women with sexual inhibition (frigidity) in six clinics.

Traditional psychiatric thought has equated the inability of a female to obtain an orgasm (particularly a vaginal orgasm during intercourse) with psychological maladjustment. The research literature generally does not support this position. The present paper describes the psychological characteristics of 44 frigid women who applied for treatment of their sexual problem at two university hospital sex clinics and 26 women selected for treatment by the same criterion, but treated in private practice. Presented for comparison are 53 female neurotics from a Temple University Hospital psychotherapy study, a sample of 65 consecutive female walk-ins of mixed psychiatric diagnosis from the Psychiatric Outpatient Clinic of Temple Hospital, and a group of 35 female college student sophomores from Temple University who comprised the normal sample. A battery of psychological tests including the MMPI, the Institute for Personality and Ability Testing--Self-Evaluation Form (IPAT), the Symptom Check List, and the Eysenck Personality Inventory were given to each group. The data indicate that female patients who apply to a sex dysfunction clinic, complaining primarily of sexual inhibition, appear as a group identical to a normal control group in terms of their psychological profile and less neurotic than psychiatric outpatients, with the exception that the normals were less depressed. When women with primary orgasmic dysfunction from the above three samples were combined and compared to those with secondary orgasmic dysfunction (using Masters and Johnson's criterion), the groups were identical, at least from a global psychological perspective. We suggest that little else can be gained by assessing global personality characteristics. Without discarding the primary and secondary classifications a potentially more fruitful approach would be to develop instruments that would measure specific dimensions, such as sexual misinformation, specific sexual anxiety or guilt, or resentment or hostility directed toward the immediate sexual partner. A scale to measure specific phobic-like sexual anxiety, in addition, would have treatment implications because of the recently demonstrated effectiveness of specific anxiety-reducing techniques, such as systematic desensitization. Specific scales can also be useful in the assessment and prediction of outcome in psychotherapy.

Truax factors, speech characteristics, and therapeutic outcome.

Initial interview ratings of therapist accurate empathy, unconditional positive regard, and self-congruence were correlated with nonlexical speech characteristics and outcome of individual psychotherapy. Speech characteristics of both patients (greater total speech time, shorter pause time following therapists' comments, and faster reaction times) and therapists (fewer speech units) were significantly related to improved outcome. While Rogers-Truax factors were unrelated to outcome, they were related to speech characteristics of both patient and therapist. Furthermore, patients whose therapists showed high levels of the Truax factors tended to increase their average speech durations and total speech time during the course of the initial interview.

Differences between behavior therapists and psychotherapists.

Patient-therapist interaction patterns of three experienced behavior therapists and three matched analytically oriented therapists were compared. Each therapist saw ten patients in short-term individual therapy. The more active behavior therapists dominated the conversation in terms of speech time, more frequently offered explicit advice and instructions, gave more direct information, presented their own value judgments, and exerted greater control over the content of the interaction than did psychotherapists. Although both groups provided a warm and accepting atmosphere, behavior therapists showed higher levels of accurate empathy, interpersonal contact, and therapist self-congruence. Patients viewed behavior therapists as more authoritarian and believed that psychotherapists encourage greater independence. It was concluded that the two therapy approaches to patients were consistent with theoretical models of each.

Short-term analytically oriented psychotherapy versus behavior therapy.

Ninety-four outpatients with anxiety neurosis or personality disorder were randomly assigned for four months to a waiting list, behavior therapy, or psychoanalytically oriented therapy. The target symptoms of all three groups improved significantly, but the two treated groups improved equally well and significantly more than those on the waiting list. There were no significant differences among the groups in work or social adjustment; however, the patients who received behavior therapy had a significant overall improvement at four months. One year and two years after the initial assessment, all groups were found to be equally and significantly improved.